COMPLIANCE INFO_1997-2006 - Laserfiche WebLink

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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERG ND STORAGE TANK PROGRAM&E WORKSHEET APPLICANT BI ING NAME P LICANT CONTACT NAME TANK ID # (s): APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE �� % l / r-,\ CITY STATE • •1 ; - 1�ZIP PIPING REPAIR FEE = $267 / FACILITY C•D • $125 PER TANK AFTER FIRST TANK APPLICANT BI ING NAME P LICANT CONTACT NAME TANK ID # (s): APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE l r-,\ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Installation Repair Retrofit L uaz�: VC5;�26,4;—,Closure PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK i 1996-1999 2000 2001 TEMPORARY CLOSURE FEE = $267 / FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PIPING REPAIR FEE = $267 / FACILITY $ $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $8 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK i # TANKS X $267 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY 4LLATION PLAN Check and Consti TANK ID # (s) : I PLAN CHECK FEE = $712 / FACILITY I $ REPAIR PLAN CHECK TANK ID # (s) : $ TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $267 / FACILITY $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 89/ HOUR $ $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR SAMPLING INSPECTION FEE _ $ 89/ HOUR $ _.--___ _._ _.._�__..__..—. .•. ..—. ............ ......rrvv.�.rv......... --cn-1-.V—r-I Mli. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 8-1-01)